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CleveLabs Laboratory Course System Teacher Edition

2006 Cleveland Medical Devices Inc., Cleveland, OH.


Property of Cleveland Medical Devices. Copying and distribution prohibited.
CleveLabs Laboratory Course System Version 6.0
Electrocardiography I Laboratory






CleveLabs Laboratory Course System Teacher Edition
Electrocardiography I Laboratory

2006 Cleveland Medical Devices Inc., Cleveland, OH.
Property of Cleveland Medical Devices. Copying and distribution prohibited.
CleveLabs Laboratory Course System Version 6.0

2
Introduction

The body relies on the heart to circulate blood throughout the body. The heart is responsible for
pumping oxygenated blood from the lungs out to the body through the arteries and also
circulating deoxygenated blood back to the lungs from the body through the veins. The heart is
divided into four chambers and each chamber is responsible for a different part of the circulatory
process mentioned above. Deoxygenated blood first enters the right atrium via the vena cava,
where it is then pumped into the right ventricle. The right ventricle pumps this deoxygenated
blood through the pulmonary artery to the lungs, where it flows through the alveoli, receives
oxygen, and then is returned to the heart through the pulmonary vein and into the left atrium. The
left atrium then pumps this oxygenated blood into the left ventricle, where then it is pumped out
to the rest of the body through the aorta. This process of contracting the different chambers is
highly coordinated and the coordination is controlled by specialized regions of the heart
responsible for electrical stimulation of cardiac muscle. Like several other bioelectrical signals,
the electrical impulses generated by the heart can be measured on the surface of the skin with
electrodes.

Using surface electrodes the cardiac potential of the heart can be measured and correlated with
regions of cardiac excitation. This measurement is called an electrocardiogram (ECG). The ECG
can be used to evaluate cardiac function, heart rate, and cardiac arrhythmias. The electrical
activation that creates the normal heartbeat can in some instances cause abnormal cardiac
function. Disorders such as bradycardia (slow heart rate), tachycardia (fast heart rate), and
electrical conduction problems such as bundle branch blocks can be all diagnosed from the ECG.

Equipment required:

CleveLabs Laboratory Kit
CleveLabs Software
Four (4) Snap Electrodes and Snap Leads
Microsoft

Excel, MATLAB

, or LabVIEW


Protractor



CleveLabs Laboratory Course System Teacher Edition
Electrocardiography I Laboratory

2006 Cleveland Medical Devices Inc., Cleveland, OH.
Property of Cleveland Medical Devices. Copying and distribution prohibited.
CleveLabs Laboratory Course System Version 6.0

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Background

Cardiac Contraction

As mentioned above, a series of events occur in a specific order during a normal heartbeat. This
process is called the cardiac cycle. The cardiac cycle can be broken down into two components,
systole and diastole. Diastole occurs when the heart muscle is relaxed and begins to fill with
venous blood in the right atrium and oxygenated blood in the left atrium. Systole is the time
when the heart contracts. During systole, the heart forces oxygenated blood out of the left
ventricle and deoxygenated blood to the lungs through the right ventricle.

Deoxygenated blood first enters the heart via the superior and inferior vena cava and fills the
right atrium (Fig 1). Contraction of the atria causes this blood to be pumped into the right
ventricle. After blood fills the right ventricle, it contracts and the tricuspid valve closes,
preventing backflow of venous blood into the right atrium. As the right ventricle contracts to
pump venous blood to the lungs, the pulmonary valve opens to allow the blood to flow through
the pulmonary artery to the lungs. The valve then closes to prevent backflow of the blood into
the right ventricle. This blood then flows to the lungs and the red blood cells receive oxygen.
This oxygenated blood then returns to the heart via the pulmonary vein and fills the left atrium.
As the left atrium contracts, the mitral valve opens, sending blood into the left ventricle. Similar
to the right ventricle, as the left ventricle contracts, the mitral valve closes to prevent backflow
into the atria, and the aortic valve opens, sending the oxygenated blood out of the heart through
the aorta. After this oxygenated blood flows through the aorta, the aortic valve closes again to
prevent backflow of this blood into the left ventricle.










Right Atrium
Left Atrium
Lungs
Mitral Valve
Left Ventricle
Tricuspid
Valve
Right Ventricle
Figure 1: Blood in the heart travels from the right atrium to the right ventricle and into the
lungs. After receiving oxygen in the lungs, the blood travels to the left atrium, the left
ventricle and then out to the body.


CleveLabs Laboratory Course System Teacher Edition
Electrocardiography I Laboratory

2006 Cleveland Medical Devices Inc., Cleveland, OH.
Property of Cleveland Medical Devices. Copying and distribution prohibited.
CleveLabs Laboratory Course System Version 6.0

4
Special Conductive Tissues in the Heart

There are several specialized regions within the heart to initiate electrical signals that cause
cardiac contraction (Fig 2). The primary area responsible for cardiac activation is the sinus node
(also known as the sinoatrial or SA node). The SA node is located at the top of the right atrium
and is the major structure responsible for pacing the heart. Connecting the SA nodes to the
atrioventricular (AV) nodes are the internodal pathways. These internodal pathways are located
along the walls of the right atrium. The electrical signal propagates down the internodal
pathways and enters the AV node. At the AV node the signal is slightly delayed. The AV node
is located in the heart septum, between the right and left atrium. After the AV node, the
electrical signal flows through the Bundle of His, located in the septal wall between the left and
right ventricles. The Bundle of His then divides into two branches, the right branch and left
branch. These branches continue along the septal wall, and then go into the Purkinje fibers,
which innervate the right and left ventricular walls.


SA Node AV Node
Bundle of His
Perkinje Fibers




Origin of the ECG Signal

In normal cases, the SA node is the hearts natural pacemaker with the autonomic nervous
system to regulate its excitation. Therefore, the electrical impulse responsible for the cardiac
cycle originates at the SA node. Pulses from the SA node propagate via the internodal fibers of
Figure 2: Conducting Pathways of the Heart


CleveLabs Laboratory Course System Teacher Edition
Electrocardiography I Laboratory

2006 Cleveland Medical Devices Inc., Cleveland, OH.
Property of Cleveland Medical Devices. Copying and distribution prohibited.
CleveLabs Laboratory Course System Version 6.0

5
the right atrium, and then to the left atrium, causing immediate atrial contraction. This electrical
potential then travels to the AV node. At the AV node, the depolarization potential is then
delayed, allowing the atria to fully contract. This delay allows the atrium to completely empty
its contents into the ventricles before ventricular contraction. After this delay in the AV node,
the potential travels down the Bundle of His, which splits into the right and left branch bundles.
These bundles then innervate the ventricular walls via the Purkinje fibers. When the signal
reaches the Purkinje fibers, ventricular contraction occurs, sending blood from the right ventricle
into the lungs and blood from the left ventricle out the aorta. This process then repeats for the
next heartbeat.

Other tissues in the heart also have natural pacing rates controlled by the autonomic nervous
system. The AV node, without outside stimulation, has a natural discharge rate of 40 to 60 times
a minute, while the Purkinje fibers fire between 15 and 40 times a minute. This is in contrast to
the SA node that fires between 70 and 80 times a minute. The reason that neither the AV node
nor the Purkinje fibers are responsible for setting the heart rate is due to the discharge rate of the
SA node. The SA node fires faster than the AV node or Purkinje fibers, so these other tissues are
excited from the SA impulse rather than their own rhythmic rate.

In normal conditions, the SA node is the natural pacemaker of the heart. However, sometimes
the AV node or Purkinje fibers begin pacing faster than the SA node. This condition is known as
an ectopic pacemaker. An ectopic pacemaker occurs when electrical activation of the heart is
initiated elsewhere than the SA node.

Another condition that can lead to an ectopic pacemaker is when the signals from the SA node
are prevented from conducting to the rest of the heart. This usually occurs when the signal is
blocked at the AV node or the AV fibers that innervate the ventricles. In this instance, the SA
node fires at its own normal rate, but these signals do not conduct down to the ventricles. Since
the Purkinje fibers do not receive these impulses from the SA node, they begin to fire at their
own intrinsic rate, between 15-40 times a minute. This leads to a very slow contraction rate of
the ventricles, failing to pump blood. If this continues, the brain may become deprived of
oxygen, and the person may faint.

A more detailed description and analysis of particular cardiac arrhythmias is presented in
Laboratory session ECG II.


CleveLabs Laboratory Course System Teacher Edition
Electrocardiography I Laboratory

2006 Cleveland Medical Devices Inc., Cleveland, OH.
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Figure 3: Typical ECG with P, QRS, and T complexes marked.


Correlation of ECG to Physiological Events

The ECG signal (Fig 3) illustrates the electrical depolarization and repolarization of the heart
during a contraction. As described above, the depolarization of the cardiac muscle cells in the
atrium occurs first. Therefore, the first wave in the ECG signal corresponds to the depolarization
of the atrium. This is known as the P wave. Similarly, the start of ventricular contraction is the
QRS wave. The ventricles stay contracted for a few milliseconds until ventricular repolarization
occurs, which is seen as the T wave. Atrial repolarization typically occurs between 0.15 to 0.20
seconds after the P wave. However, this is the same time when the QRS complex occurs. The
QRS complex is of much greater amplitude than atrial repolarization so it dominates the signal.

Typical Duration and Amplitudes

The voltage of the ECG signal can vary depending on the location of the electrodes placed on the
body. If the electrodes are located close to the heart, the recorded potentials can be as high as 5
mV. However, if the electrodes are placed further apart, such as at the wrists, a typical value is
1mV. Both of these measurements, however, are small compared to electrodes placed directly in
contact with the heart muscle membrane. Here the potential can range as high as 110 mV.
Typical amplitudes are around 1mV for the top of the Q wave to the bottom of the S wave, 0.1 -
0.3 mV for the P wave, and between 0.2 - 0.3 mV for the T wave.





CleveLabs Laboratory Course System Teacher Edition
Electrocardiography I Laboratory

2006 Cleveland Medical Devices Inc., Cleveland, OH.
Property of Cleveland Medical Devices. Copying and distribution prohibited.
CleveLabs Laboratory Course System Version 6.0

7
The PQ interval (also known as the PR interval) is the amount of time from the beginning of the
P complex to the QRS complex. This represents the amount of time between the beginning of
atrial contraction and the beginning of ventricular contraction. The normal duration is
approximately 0.16 seconds. Similarly, the QT interval is the time between ventricular
contraction and ventricular repolarization. This is measured from the beginning of the Q wave to
the end of the T wave and typically lasts 0.35 seconds. The heart rate can be determined directly
from the ECG. The heart rate is the inverse of the time between similar segments in the ECG
recording. For example, if the time measured between two QRS complexes is 0.8 seconds, then
the number of beats per second is the inverse, 1.25 beats / second. In order to obtain the heart
rate per minute, you would simply multiply by 60 seconds/minute. This would yield 75 beats per
minute.

Electrode Configuration

There is a standard placement of electrodes when performing ECG recordings called a standard
bipolar limb lead. A lead refers to the potential difference between two electrodes. For this lab,
lead placement involves three leads, which are placed on the right arm (RA), left arm (LA), and
left leg (LL). The electrodes can be attached to the wrists and inner ankle, but for clinical
applications, are usually attached to the chest for a more accurate signal. Leads I, II, and III
constitute the standard limb lead ECG connected as follows:


Lead + -
I LA RA
II LL RA
III LL LA



In the table, the positive and negative signs denote the polarity of the leads. So, the positive end
of Lead I connects to the LA, while the negative end of Lead I connects to the RA. Using these
three leads, we can form what is called Einthovens Triangle. This is a representation of vectors
demonstrating the formation of the ECG signal. In interpreting these measurements, each lead is
assumed to be equivalent to measurements taken across all sides of an equilateral (Einthovens)
triangle, which is superimposed over the chest, as shown below:
Table 1. Standard bipolar limb lead ECG configuration.


CleveLabs Laboratory Course System Teacher Edition
Electrocardiography I Laboratory

2006 Cleveland Medical Devices Inc., Cleveland, OH.
Property of Cleveland Medical Devices. Copying and distribution prohibited.
CleveLabs Laboratory Course System Version 6.0

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Figure 4: Einthoven's law and lead configuration.

With Einthovens Triangle, there is an equation that relates all three vectors. Graphically,
Einthovens Law says that if the potentials of the first two leads are known, than the third lead
can be found by adding the two vectors together. Mathematically, Einthovens law states that for
the potentials on each lead:

Lead I + Lead III = Lead II

Some may notice that this equation is similar to Kirchoffs Voltage law, which states that all of
the voltages in a loop must equal zero. Using this equation, we only need to record two of the
leads. The third lead can be determined mathematically, provided that the two leads were
measured simultaneously. Einthovens Triangle also allows us to determine the mean electrical
axis of the heart. This mean electrical axis is the vector representing the summation of all the
vectors that occur in a cardiac cycle. This electrical axis can be thought of as a dipole. The
dipole illustrates the strength and direction of the hearts polarization during a cardiac cycle.
There are two ways of determining the mean electrical axis. Lead I measures lateral voltage and
the other two measure from top to bottom. One method is to measure the magnitude of the R
complex along Lead I and Lead III, and to extrapolate the vector of Lead II, which would give
the magnitude and angle of the vector. A more accurate way of measuring the mean electrical
axis would be to add the Q, R, and S potentials for the two leads, instead of only the R wave. The
QRS potentials are measured along Lead I and III, added together, and then the mean electrical
axis can be computed by finding the magnitude and direction of the vector representing Lead II.
If a complete measurement of the mean electrical axis is desired, twelve leads are required, since
the mean electrical axis is precisely defined in three dimensions, x, y, and z. In this lab, we will
only focus on the frontal plane mean electrical axis. In normal conditions, the mean electrical
axis of the heart is typically around 60 degrees.



CleveLabs Laboratory Course System Teacher Edition
Electrocardiography I Laboratory

2006 Cleveland Medical Devices Inc., Cleveland, OH.
Property of Cleveland Medical Devices. Copying and distribution prohibited.
CleveLabs Laboratory Course System Version 6.0

9





Vector Analysis of the Electrocardiogram

The ECG signal that is recorded can be derived from the Leads I-III vectors. When the ECG
signal is recorded, the vector values for each of the leads changes as the atria and then ventricles
contract. For example, as the QRS wave occurs, the lead I vector has a very small magnitude.
This describes the slow upward growth of the lead I ECG recording. As depolarization sweeps
across the atria and into the ventricles, the lead I vector begins to increase, causing the fast
growth in the lead I ECG signal that is typical of the QRS complex. Then, as more of the
ventricles depolarize, the lead I vector starts becoming smaller since all of the ventricular muscle
has become depolarized, causing the lead I vector to have zero or slightly negative magnitude,
causing the negative slope of the ECG signal in lead I. A similar analysis can be performed on
the other leads and can also explain how repolarization sweeps across the heart when the T wave
occurs.


Experimental Methods

Experimental Setup

During this laboratory you will record a standard three lead ECG. You should watch the setup
movie included with the software prior to setting up the experiment.

1. Your BioRadio should be programmed to the LabECGI configuration.


Figure 5: Mean electrical axis of the heart.



CleveLabs Laboratory Course System Teacher Edition
Electrocardiography I Laboratory

2006 Cleveland Medical Devices Inc., Cleveland, OH.
Property of Cleveland Medical Devices. Copying and distribution prohibited.
CleveLabs Laboratory Course System Version 6.0

10
kA
k|
|A
||
Jumpe| -1 c -2J
B|cRoo|c |npus
|A
kA
||
k|
Jumpe| 2 c 3J
+Ch1
-Ch1
+Ch2
+Ch3
-Ch2
-Ch3
GND
Sucjec Recc|o|ng S|es
Jumpe| 1 c -3J

Figure 6. ECG Setup

2. For this laboratory you will need to use four snap electrodes from the CleveLabs Kit.
Remember that the electrode needs to have good contact with the skin in order to get a
high quality recording. The surface of the skin should be prepared and cleaned prior to
electrode placement. For the best recordings, it is best to mildly abrade the surface with
pumice or equivalent to minimize contact resistance by removing the outer dry skin layer.
Attach one electrode on the palmar side of the right wrist, one on the palmar side of the
left wrist, one on the left leg, and one on the right leg. NOTE: The electrodes on the
arms can be placed at the wrists and the electrodes on the legs can be placed near
the ankles.

3. After the electrodes have been placed on the subject, connect one snap lead to each of the
four electrodes. Then, connect those snap leads and jumpers to input channels 1, 2, 3 and
the ground using the picture above as a reference (Fig 6). Refer to your BioRadio Users
guide for more information on setting up the system.


CleveLabs Laboratory Course System Teacher Edition
Electrocardiography I Laboratory

2006 Cleveland Medical Devices Inc., Cleveland, OH.
Property of Cleveland Medical Devices. Copying and distribution prohibited.
CleveLabs Laboratory Course System Version 6.0

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Procedure and Data Collection

1. Run the CleveLabs Course software. Log in and select the Electrocardiography I
laboratory session under the Basic Physiology subheading and click on the Begin Lab
button.

2. Turn the BioRadio ON.

3. Click on the ECG data Tab and then on the green Start button. Three channels of ECG
should begin scrolling across the screen.

4. The first part of this lab session will record normal resting ECG with the subject sitting
up and laying down. It is important that the subject is relaxed and still during this
procedure in order to prevent artifacts from contaminating the ECG signal.

5. For the first test, have the subject lie down on the floor or a cot. The subjects ECG
should begin scrolling across the monitor. You may need to adjust the plot scales to see
the ECG clearly. Instruct the subject to relax then click on the save button and record
data for approximately 10 seconds. Name the data file layingECG. Also, click on
Report to capture a screen shot of the data scrolling.



6. With the subject still laying relaxed, click on the Spectral Analysis tab to complete a
spectral analysis. Depending on your surroundings, it is likely that there is some 60Hz
noise in the signal. Note where the peak frequency of the signal occurs. Report a screen
capture of the raw, unfiltered spectral analysis screen. You may need to adjust the
scaling.



CleveLabs Laboratory Course System Teacher Edition
Electrocardiography I Laboratory

2006 Cleveland Medical Devices Inc., Cleveland, OH.
Property of Cleveland Medical Devices. Copying and distribution prohibited.
CleveLabs Laboratory Course System Version 6.0

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7. Setup filter parameters that will remove the 60Hz noise from the signal and Report a
screen capture of the filtered spectral analysis to verify this.



8. Request the subject to sit up in a chair, and place his/her arm on a table or armrest. Make
sure the subject is relaxed and quiet. Then save another 10-second segment. Name this
data file sitECG.

9. Next, instruct the subject to wave their left hand around in space while you are recording
ECG. Save this data to file and name the file ECGartifactleft.

10. Finally, instruct the subject to wave their left hand around in space while you are
recording ECG. Save this data to file and name the file ECGartifactright.





CleveLabs Laboratory Course System Teacher Edition
Electrocardiography I Laboratory

2006 Cleveland Medical Devices Inc., Cleveland, OH.
Property of Cleveland Medical Devices. Copying and distribution prohibited.
CleveLabs Laboratory Course System Version 6.0

13
Data Analysis

1. Using the Post Processing Toolbox, open the data file named sitECG.



2. Click on the spectral analysis tab and make sure you are on the time domain subtab.
Change the time scale such that one beat is shown in the window. Report a screen shot of
this to a new report.




3. Set the low pass filter to 20 Hz and examine the effect on the ECG signal. Report a
screen shot of this to your report.


CleveLabs Laboratory Course System Teacher Edition
Electrocardiography I Laboratory

2006 Cleveland Medical Devices Inc., Cleveland, OH.
Property of Cleveland Medical Devices. Copying and distribution prohibited.
CleveLabs Laboratory Course System Version 6.0

14



4. Using the post processing toolbox, open the data files labeled ECGartifactright and
ECGartifactleft. Examine each of the three leads in each file. On which leads can you
detect an ECG signal? On which leads is the ECG signal distorted? Explain why.

5. Using Excel, MATLAB, or LabVIEW, import the data file layingECG. Plot the first
four beats from channel 1. Also, determine the resting heart rate of the subject based on
this recording. Repeat this for the file exercise. Label the P, Q, R, S and T segments of
one beat on both plots.





CleveLabs Laboratory Course System Teacher Edition
Electrocardiography I Laboratory

2006 Cleveland Medical Devices Inc., Cleveland, OH.
Property of Cleveland Medical Devices. Copying and distribution prohibited.
CleveLabs Laboratory Course System Version 6.0

15



6. Using Excel, MATLAB, or LabVIEW, open the file layingECG. Einthovens Law
stated that the sum of the potentials from all three channels should equal zero. Using this
relationship, calculate what lead two should be, as if data for the first four beats was only
available from leads I and III. Plot this calculated lead II, along with the measured lead II.
Then, subtract the calculated lead II from the measured lead II and plot this error over
time. Give a mean error between the calculated lead II and the actual lead II
measurements.





CleveLabs Laboratory Course System Teacher Edition
Electrocardiography I Laboratory

2006 Cleveland Medical Devices Inc., Cleveland, OH.
Property of Cleveland Medical Devices. Copying and distribution prohibited.
CleveLabs Laboratory Course System Version 6.0

16



7. Using Einthovens triangle, the mean electrical axis can be approximated by adding the
vectors for leads I and III, and then computing the direction and magnitude of the lead II
vector, which is the mean electrical axis of the heart.

To do this measurement, draw a figure similar to the one next to Einthovens triangle (Fig
4), except omit the line representing lead II. Use a protractor to ensure that the angle
between leads I and III is 120 degrees. For both the lead I and lead III vectors, draw
twenty evenly spaced tics on the vectors, ranging from 0 to 2 mV.

8. One way of determining the mean electrical axis is to measure the amplitude of the R
wave on leads I and III. Use Excel to determine the mean amplitude of the R wave for
leads I and III over three or more beats. Once known, draw a line perpendicular to the
lead I and a line perpendicular to lead III vectors at the value of the R wave for the
respective leads. (i.e., if the mean R wave amplitude is .8 for Lead I and .6 for Lead III,
find the mark corresponding to .8 mV on Lead I, and draw a perpendicular line, and do
the same for Lead III) Find the intersection of these two lines, and record the magnitude
and direction of this vector. Remember that zero degrees is measured from the lead I
vector. This vector we computed is the lead II vector, which indicates the mean electrical
axis of the heart.

9. On the same graph, repeat the above steps on the file with the subject sitting up.






CleveLabs Laboratory Course System Teacher Edition
Electrocardiography I Laboratory

2006 Cleveland Medical Devices Inc., Cleveland, OH.
Property of Cleveland Medical Devices. Copying and distribution prohibited.
CleveLabs Laboratory Course System Version 6.0

19
References

1. Guyton and Hall. Textbook of Medical Physiology, 9
th
Edition, Saunders, Philadelphia,
1996.

2. Normann, Richard A. Principles of Bioinstrumentation, John Wiley and Sons, New York,
1988.

3. Rhoades, R and Pflanzer, R. Human Physiology. Third Edition. Saunders College
Publishing, Fort Worth 1996.

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